Cellulitis Workup

  • Author: Thomas E Herchline, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 7, 2011
 

Approach Considerations

Generally, no workup is required in uncomplicated cases of cellulitis that meet the following criteria:

  • Small area of involvement
  • Minimal pain
  • No systemic signs of illness (eg, fever, chills, dehydration, altered mental status, tachypnea, tachycardia, hypotension)
  • No risk factors for serious illness (eg, extremes of age, general debility, immunocompromised status)

Laboratory studies are unnecessary in most patients with cellulitis. As with laboratory studies, most cases of cellulitis do not require imaging.

Because the bacterial etiology of cellulitis in typical cases is highly predictable, additional procedures also usually are not necessary. However, in more severe disease or unique clinical scenarios, additional procedures may be indicated.

Jenkins et al have developed guidelines for the management of patients who require hospitalization for cellulitis or cutaneous abscess. The guidelines were shown to decrease the use of resources without an adverse affect on clinical outcomes.[51]

See the image below.

Guidelines for the management of patients who requGuidelines for the management of patients who require hospitalization for cellulitis or cutaneous abscess. Adapted from Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011 Feb 28.
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Moderate-to-Severe Cases and Systemic Symptoms

The following laboratory tests may be considered in patients who present with moderate to severe cellulitis and/or systemic symptoms:

  • A complete blood cell (CBC) count often shows leukocytosis in the setting of severe disease. Leukopenia may also be present in severe disease, especially in cases of toxin-mediated cellulitis.
  • The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are also frequently elevated, especially in patients with severe disease requiring prolonged hospitalization.[46]
  • In most cases of cellulitis, blood cultures are neither necessary nor cost-effective.[52, 53] However, these studies should be obtained in patients who are admitted for moderate to severe disease,[54] such as in patients with cellulitis complicating lymphedema,[55] because the prevalence of bacteremia is higher in these individuals. Blood cultures are also recommended in patients with cellulitis involving specific anatomic sites, such as the oral and ophthalmic area, and in those with a history of contact with potentially contaminated water.[56]
  • Gram stain, whether obtained via biopsy or aspiration of the infected area, has a low yield and is unnecessary in most cases unless purulent material is draining or bullae or abscess is present.
  • If recurrent episodes of cellulitis are suspected to be secondary to tinea pedis, mycologic investigations are advisable.
  • Baseline creatinine studies may be helpful to assess baseline renal function in order to correctly prescribe antimicrobials.
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Ultrasonography and MRI

Current data suggest that ultrasonography may play a role in the detection of occult abscess and direction of care, especially in an emergency department setting.[57] Ultrasonographic-guided aspiration of pus has been shown to shorten hospital stay and fever duration in children with cellulitis.[58] If necrotizing fasciitis is a concern, magnetic resonance imaging (MRI) may help to rule out this condition[59] ; however, strong clinical suspicion of this disease should prompt surgical consultation without delay for imaging.

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Biopsy, Aspiration, and Dissection

Needle aspiration should be performed only in selected patients and/or in unusual cases, such as diabetic patients, immunocompromised individuals, patients with neutropenia or those whose condition is not responding to empiric therapy, and patients with a history of animal bites or immersion injury.[4, 52, 60]

Aspiration or punch biopsy of the inflamed area may have a culture yield of 2-40% and is of limited clinical value in most cases.[61] Incision and drainage of an abscess with Gram stain and culture yields positive culture results in more than 90% of cases.[54]

Dissection to the underlying fascia to assess for necrotizing fasciitis is indicated upon clinical concern following initial evaluation and imaging studies.[62]

Biopsy is not routine but may be performed in an attempt to rule out a noninfectious entity. Tissue stains and microscopy reveal findings of soft-tissue inflammation. Leukocyte infiltration, capillary dilatation, and bacterial invasion of tissue are observed.

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Contributor Information and Disclosures
Author

Thomas E Herchline, MD  Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Coauthor(s)

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Danny Lee Curtis, MD  Clinical Assistant Professor of Medicine, University of South Florida College of Medicine; Consulting Staff, James A Haley Veterans Hospital

Danny Lee Curtis, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Vinod K Dhawan, MD, FACP, FRCP(C), FIDSA  Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCP(C), FIDSA is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada

Disclosure: Pfizer Inc Honoraria Speaking and teaching

Eric S Halsey, MD  Head, Virology Department, Naval Medical Research Center Detachment-Peru (NMRCD-Peru); Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Eric S Halsey, MD is a member of the following medical societies: Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Isaac P Humphrey, MD  Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Assistant Professor of Internal Medicine, Wright State University Boonshoft School of Medicine

Isaac P Humphrey, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Sungnack Lee, MD  Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea

Sungnack Lee, MD is a member of the following medical societies: American Dermatological Association

Disclosure: Nothing to disclose.

Mark Louden, MD, FACEP  Assistant Medical Director, Emergency Department, Duke Raleigh Hospital

Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Giuseppe Micali, MD  Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy

Giuseppe Micali, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Christen M Mowad, MD  Associate Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Maria R Nasca, MD, PhD  Assistant Professor, Department of Dermatology, University of Catania School of Medicine, Italy

Disclosure: Nothing to disclose.

Barry J Sheridan, DO  Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred A Lopez, MD  Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Baxter International and Johnson & Johnson Royalty Other

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Dennis Cunningham, MD, and Robert Edelman, MD, to the development and writing of the source articles.

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Mild cellulitis with a fine lacelike pattern of erythema. This lesion was only slightly warm and caused minimal pain, which is typical for the initial presentation of mild cellulitis.
Cellulitis involving the hand.
Severe cellulitis of the leg in a woman aged 80 years. The cellulitis developed beneath a cast and was painful and warm to the touch. Significant erythema is evident. The margins are irregular but not raised. An ulcerated area is visible in the center of the photograph.
Burns complicated by cellulitis. The larger lesion is a second-degree burn (left), and the smaller lesion is a first-degree burn (right), each with an expanding zone of erythema consistent with cellulitis.
Cellulitis due to documented Vibrio vulnificus infection. Image courtesy of Kepler Davis.
A case of cellulitis without associated purulence in an infant. Note the presence of lymphedema, a risk factor for cellulitis (Photo courtesy of Amy Williams).
Patient with cellulitis of the left ankle. Note the area of drainage. This cellulitis was caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). (Photo courtesy of Texas Dept. of Public Health)
Abscess and associated cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). (Photo courtesy of Texas Dept. of Public Health)
Hand cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).
Guidelines for the management of patients who require hospitalization for cellulitis or cutaneous abscess. Adapted from Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011 Feb 28.
Table. Empiric Antibiotic Therapy of Cellulitis by Etiology and Anatomic Location
LocationLikely



Organisms



Other



Organisms



Complication/ DiscussionAntibiotic Regimen -- Oral/ OutpatientIndication for HospitalizationAntibiotic



Regimen -- Parenteral/ Hospitalized



Uncomplicated cellulitisGroup A streptococci and Staphylococcus aureusCephalexin or dicloxacillin



or clindamycin



Cefazolin or oxacillin



or nafcillin



Cellulitis in which methicillin-resistant S aureus is a concernGroup A streptococci and S aureus[(Cephalexin or dicloxacillin or clindamycin) plus trimethoprim/ sulfamethoxazole]



or



Clindamycin



Vancomycin
Dog bitePasteurella canis (50% of wounds)



S aureus



Streptococcus pyogenes



Staphylococci, streptococci



Aerobes --Moraxella and Neisseria



Anaerobes --Fusobacterium, Bacteroides, Porphyromonas, and Prevotella



Capnocytophaga canimorsus may cause sepsis in patients with asplenia/hepatic disease.



Avoid first-generation cephalosporins/ erythromycin/ dicloxacillin.



High likelihood of infection -- Prophylactic antibiotics indicated for the following wounds: deep puncture, hands, requiring surgical repair, immunocompromised host, venous or lymphatic compromise, crush injury.



Requires close follow-up care within 24-48 h.



Amoxicillin/ clavulanate



Penicillin allergic --



(Clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)



Deep wounds or severe wounds;



infections not responding to oral antibiotics



Third-generation cephalosporin (ceftriaxone [Rocephin]) plus metronidazole



or



beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or



fluoroquinolone plus metronidazole



or



carbapenem (ertapenem)



Human biteEikenella corrodens (gram-negative anaerobe, 29% of wounds)



Aerobic gram-positive cocci, anaerobes



Lacerations over metacarpophalangeal joints should be considered human bites; anesthetize wounds and irrigate; reevaluate within 24-48 h.



Intercanine distance >3 cm is likely bite from adult; if wound to child, consider abuse.



Amoxicillin/ clavulanate



Penicillin allergic - - (Clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)



Third-generation cephalosporin (Rocephin) plus metronidazole



or



beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam)



or



fluoroquinolone plus metronidazole



or



carbapenem (ertapenem)



Cat bitePasteurella multocida and P septica (75% of wounds)Staphylococci, streptococci, Bacteroides, Peptostreptococcus, Actinomyces, Fusobacterium, Porphyromonas, and Veillonella parvulaAvoid first-generation cephalosporins/ erythromycin/ dicloxacillin



High likelihood of infection -- Prophylactic antibiotics indicated for the following wounds: deep puncture, hands, requiring surgical repair, immunocompromised host, venous or lymphatic compromise.



Requires close follow-up care within 24-48 h.



Amoxicillin/ clavulanate



Penicillin allergic -- (Clindamycin or metronidazole) plus



(doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole)



Deep wounds or severe wounds; infections not responding to oral antibioticsThird-generation cephalosporin (Rocephin) plus metronidazole



or



beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or



fluoroquinolone plus metronidazole



or



carbapenem (ertapenem)



Preseptal (periorbital) cellulitisHaemophilus influenzae type b, Streptococcus pneumoniae, S aureus, other streptococcal species, and anaerobesNocardia brasiliensis, Bacillus anthracis, Pseudomonas aeruginosa, Neisseria gonorrhoeae, Proteus species, Pasteurella multocida, Mycobacterium tuberculosisLargest study indicates that H influenzae type b and S pneumoniae not diminished in facial cellulitis as a result of immunizations[8] Amoxicillin-clavulanate, cefpodoxime, cefdinirAge < 1 y/ more severe disease require intravenous antibioticThird-generation cephalosporin (Rocephin)
Lower extremity --



Complicating saphenous venectomy site after coronary bypass grafting



No pathogen identifiable in most infections --



Non-group A beta-hemolytic streptococci most likely organism; S aureus less common



Recurrent episodes common; may be associated with rigors, extreme fatigue, myalgias, and hypotension; typically associated with tinea pedis (toe web cultures may be useful in establishing probable pathogen) Dicloxacillin or cephalexin.



Add trimethoprim/ sulfamethoxazole or tetracycline or clindamycin if methicillin-resistant S aureus is present.



First-generation cephalosporin (cefazolin); clindamycin; vancomycin
Breast/arm - -



Complicating breast cancer surgery/lymph node dissection



No pathogen identifiable in most infections --



Non-group A beta-hemolytic streptococci most likely organism



Dicloxacillin, cephalexin. Add trimethoprim/ sulfamethoxazole or tetracycline or clindamycin if methicillin-resistant S aureus is present.Fever, recent chemotherapy, neutropeniaMultiple regimens, none clearly superior --Piperacillin or ceftazidime plus aminoglycoside;



or



ciprofloxacin plus beta-lactam



or



monotherapy with piperacillin/tazobactam or cefepime



Aquatic environment --



Fresh water/ salt water/ brackish water/ swimming pools/ aquarium



Puncture/ laceration



Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Vibrio species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and othersA hydrophila and Vibrio vulnificus may produce rapidly progressive soft-tissue infection and sepsisFluoroquinolone (eg, ciprofloxacin or levofloxacin)Third- or fourth-generation cephalosporin (eg, ceftazidime or cefepime) or fluoroquinolone (eg, ciprofloxacin or levofloxacin)
Clenched-fist injuryE corrodens (gram-negative anaerobe, 29 % of wounds); aerobic gram-positive cocci, anaerobesLacerations over metacarpophalangeal joints should be considered human bites; anesthetize wounds and irrigate; reevaluate within 24-48 h



Lacerations of extensor tendon



Amoxicillin/ clavulanate; penicillin allergic - (clindamycin or metronidazole) plus (doxycycline or cefuroxime or trimethoprim/ sulfamethoxazole) Failure to respond to oral therapy marked by increasing pain and swelling or purulent drainageFirst-generation cephalosporin (cefazolin)



or



beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam)



Odontogenic facial cellulitisAerobic and facultative organisms: group A beta-hemolytic streptococci, Neisseria and Eikenella species



Anaerobes: Prevotella and Peptostreptococcus species



Require extraction or root canalAmoxicillin-clavulanate



or



clindamycin



Beta-lactam/beta-lactamase inhibitor (eg, ampicillin/sulbactam) or



clindamycin



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